THE CLINICAL SYNDROME
A significant number of patients who suffer form noncardiogenic chest pain suffer from costosternal joint pain. Most commonly, the costosternal joints become a source of pain due to inflammation as a result of overuse or misuse or due to trauma secondary to acceleration/ deceleration injuries or blunt trauma to the chest wall. With severe trauma, the joints may sublux or dislocate. The costosternal joints are also susceptible to the development of arthritis, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter’s syndrome, and psoriatic arthritis. The joints are also subject to invasion by tumor either from primary malignancies, including tymona, or from metastic disease.
SIGNS AND SYMPTOMS
Physical examination of the patient suffering form costosternal syndrome will reveal that the patient will vigorously attempt to splint the joints by keeping the shoulders stiffly in neutral position. Pain is reproduced with active protraction or retraction of the shoulder, deep inspiration, and full elevation of the arm. Shrugging of the shoulder may also reproduce the pain. Coughing may be difficult, and this may lead to inadequate pulmonary toilet in patients who have sustained trauma to the anterior chest wall. The costosternal joints and adjacent intercostal muscles may also be tender to palpation. The patient may also complain of a clicking sensation with movement of the joint.
Irritation of the costosternal joints from overuse of exercise equipment can cause costosternal syndrome.
Neuropathic pain involving the chest wall may also be confused or coexist with costosternal syndrome. Examples of such neuropathic pain include diabetic polyneuropathies and acute herpes zoster involving the thoracic nerves. The possibility of diseases of the structures of the mediastinum remain ever present and at times can be difficult to diagnose. Pathologic processes that inflame the pleura, such as pulmonary embolus, infection, and Bornholm’s disease, may also confuse the diagnosis and complicate treatment.
Initial treatment of the pain and functional disability associated with costosternal syndrome should include a combination of the nonsteroidal anti-inflammatory drugs or the cyclooxygenase-2 inhibitors. The local application of heat and cold may also be beneficial. The use of an elastic rib belt may also help provide symptomatic relief and help protect the costosternal joints from additional trauma. For patients who do not respond to these treatment modalities, the following injection technique with local anesthetic and steroid may be a reasonable next step.
Intra-articular injection of the costosternal joint is performed by placing the patient in the supine position; proper preparation with antiseptic solution of the skin overlying the affected costosternal joints is then carried out.
Correct needle placement for injection technique for costosternal syndrome
Patients suffering from pain emanating from the costosternal joint will often attribute their pain symptomatology to a heart attack. Reassurance is required, although it should be remembered that this musculoskeletal pain syndrome and coronary artery disease can coexist. Tietze’s syndrome which is painful enlargement of the upper costochondral cartilage associated with viral infections, can be confused with costosternal syndrome, although both respond to the aforementioned injection technique. The use of physical modalities including local heat as well as gentle range of motion exercises should be introduced several days after the patient undergoes this injection for costosternal joint pain. Vigorous exercises should be avoided because they will exacerbate the patient’s symptomatology. Simple analgesics and nonsteroidal anti-inflammatory drugs may be used concurrently with this injection technique.